Provider Demographics
NPI:1790813244
Name:GIBSON, BERNELLA J (COTA)
Entity Type:Individual
Prefix:
First Name:BERNELLA
Middle Name:J
Last Name:GIBSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 MEEKINS DRIVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407
Mailing Address - Country:US
Mailing Address - Phone:540-786-1789
Mailing Address - Fax:540-786-1792
Practice Address - Street 1:3500 MEEKINS DRIVE
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407
Practice Address - Country:US
Practice Address - Phone:540-786-1789
Practice Address - Fax:540-786-1792
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000693224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA496665Medicare Oscar/Certification